Provider Demographics
NPI:1265950737
Name:SULLIVAN, SCOTT JEFFREY (DDS)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:JEFFREY
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 185TH AVE E
Mailing Address - Street 2:
Mailing Address - City:LAKE TAPPS
Mailing Address - State:WA
Mailing Address - Zip Code:98391-9474
Mailing Address - Country:US
Mailing Address - Phone:253-468-6113
Mailing Address - Fax:
Practice Address - Street 1:3516 S 47TH ST STE 104
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-4427
Practice Address - Country:US
Practice Address - Phone:253-475-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60758007122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist